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HIV and AIDS in Brazil

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Brazil represents the largest number of people living with HIV in Latin America and accounts for 40% of all new infections in the region.

The HIV and AIDS epidemic in Brazil is classified as stable at the national level, with a prevalence rate in the general population of 0.6%.1 However, HIV prevalence varies geographically, with higher levels noted in the South and Southeast of the country.2

In 2015, 830,000 people were living with HIV compared to 700,000 in 2010. In the same year there were 44,000 new infections, 1000 more than in 2010. This reflects the fact that new infections have risen between 2010 and 2015 by 4%.3. In 2015, 15,000 people died due to AIDS related illnesses, a rate that has remained stable since 2010.4

Brazil represents the largest number of people living with HIV in Latin America and accounts for 40% of all new infections in the region. This is in part due to its large population in comparison to other Latin American countries.5 Worldwide, it is one of 15 countries which represent 75% of the global number of people living with HIV.6

Key affected populations in Brazil

Data reveals that the HIV epidemic is concentrated among key populations in Brazil. Additionally, the last 10 years have also revealed changes in the age profile of reported HIV and AIDS incidence. Most notable has been a shift to younger men and women. While the highest rates of infection are reported among people aged 30–49, there is an increasing trend in detection rates among young people aged 15–24 and adults aged over 50.7

People who inject drugs in Brazil

The government of Brazil implements a harm reduction strategy to address the needs of people who inject drugs (sometimes referred to as PWID). In the 1990s, HIV and AIDS cases linked to people who inject drugs reached 25% in Brazil. However, the implementation of an expanded programme has shown a dramatic reduction of up to 72% between 1996 and 2006.8

HIV prevalence among people who inject drugs in Brazil has remained relatively unchanged, ranging between 5% and 5.9% during the period 2008 through 2013.9 However, a 2015 study of people who use drugs in eight Brazilian cities found HIV prevalence to be at 9.9%.10

As part of its harm reduction strategy for people who inject drugs, the Brazilian government continues to provide supplies including free needle exchanges as a key component to achieve a reduction in the transmission of HIV and other blood-borne infections. More recently, trends are showing increasing dependence on non-injecting drug use including crack and other stimulants.11 Varied strategies and diversified approaches are required to address these practices.

Prisoners in Brazil

HIV prevalence among people who inject drugs who are also part of the prison population in Brazil continues to be higher than that of the general population. The incidence of HIV is accelerated by issues of overcrowding and violence, and is exacerbated by other social and welfare vulnerabilities and legal and policy constraints.12

In January 2014, the Ministry of Health launched the National Policy on Comprehensive Health Care for Prison Populations, which aims to ensure access to the Unified Health System for this population.13 The package of interventions to address HIV in prisons settings will include: access to HIV testing and counselling (HTC), HIV treatment and care, information, education and communication, prevention, diagnosis and treatment of tuberculosis, availability of condom and needle and syringe programmes.

Freedom to Look project in Brazilian prisons

In 2013, the United Nations Office on Drugs and Crime (UNODC) launched the Freedom to Look Project in the country, in collaboration with the Brazilian government. The project works with prison system workers on prisoners’ human rights, focusing on gender, violence and health issues, specifically the prevention of HIV, viral hepatitis and tuberculosis.14

As of 2015, the Freedom to Look Project was operating in four Brazilian prisons.15

Sex workers in Brazil

The current prevalence of HIV among female sex workers in Brazil is 4.9%.1617 Sex work is legal in Brazil, although owning a brothel or engaging in any business associated with sex work is criminalised.18 The government has implemented HIV prevention interventions through the Ministry of Health which involve a rights-based approach. These include campaigns that promote the self-esteem and rights of sex workers and emphasise consistent condom use.

As a result of lobbying by sex worker organisations, sex work has been included as a profession in Brazil, thereby entitling sex workers to social security and other work benefits.19

Knowledge of HIV prevention methods and condom use with clients is reported as high among female sex workers – 90% used a condom with their most recent client.2021 However, only 17.5% of sex workers in Brazil were tested for HIV during the past 12 months.22

A 2015 review of more than 50 condom use studies in Brazil found the need to have or buy condoms and situations of violence were the key factors associated with condom use for sex workers. Overall, it found 21.4% of female sex workers regularly used condoms with steady partners during vaginal sex and 29.4% during anal sex. With clients 69.7% regularly used condoms during vaginal sex and 64% during anal sex. However, it emphasised that condom use studies tend to focus on adolescents and women, which means knowledge remains limited when it comes to other key affected populations.23

Community empowerment has been identified as a key success factor in promoting and sustaining change, to address health and human rights among sex workers.24 However, sex workers in Brazil still face structural barriers and exposure to HIV as a result of fear of violence and socio-economic constraints, which increase high risk practices among the population.

During the past five years, HIV prevention and sex worker rights interventions have become more restricted in scope as a result of declining national and international political and financial support. At the national level, the Brazilian Minister of Health vetoed and replaced a rights-based anti-stigma HIV prevention campaign, created in partnership between sex workers and the STD/AIDS department of the Ministry of Health. The restructured campaign focused exclusively on condom use without any reference to human rights or citizenship, which is indicative of the ongoing challenges for the Brazilian sex worker community.25

Men who have sex with men in Brazil

HIV transmission among men who have sex with men (sometimes referred to as MSM) in Brazil remains common, with 10.5% of this group living with HIV.26

In a 2013 study, HIV prevalence among men who have sex with men was found to range from 9.1% to 16%.27 Geography and other factors such as age and socio-economic realities affect prevalence rates.

For example, a 2012 survey conducted in São Paulo found an HIV prevalence of 15.4% among men who have sex with men who were over the age of 18 years. Among those aged 18 to 24 years, HIV prevalence was already 6.4%.28

During the past decade, there has also been an increase of AIDS cases among men who have sex with men. This has also occurred among young men (aged 15–24) who have sex with men.

Despite the gains of the past 20 years, the proportion of men reporting unsafe sex in high-risk settings has dramatically increased.29

There is a need to address the structural barriers affecting the uptake of services, as well as implementing a comprehensive approach towards the prevention and treatment of HIV among men who have sex with men. To be effective this approach must take into account the community and social norms that contribute to individual risks.

For example, a 2015 survey of just under 4,000 men who have sex with men in Brazil found 16% had experienced some form of sexual violence.30 Brazil also has the highest number of murders of transgender and gender-diverse people in the world, accounting for 800 of the 2000 murders that occurred globally in 2015. The vast majority of killings go unpunished.31

HIV testing and counselling in Brazil

Over the past three years, the Brazilian Department of STD/AIDS and Viral Hepatitis (DDAHV) has been decentralising its HIV testing services, including increasing the use of rapid tests (finger-prick) in primary care services throughout the country. In 2015, Brazil began providing self-testing kits to the general population. These kits were made available free of charge from pharmacies, medication distribution centres, health services and government health programmes, as well as through the mail. By March 2016, more than 72,000 people had accessed the online platform for self testing and around 2,900 self-testing kits had been distributed.32

Strategies to increase testing among key populations have also been introduced. In 2013, 40 NGOs were trained in rapid testing for HIV, with a focus on people most at risk. This has expanded access to key populations by providing access at times and locations that better suit their needs.33

Official figures for HIV testing rates relate to 2013 data, which reports that 37%, of sexually active adults had been tested at least once for HIV.34 However, testing coverage was found to drop to 13% (9.7% among men and 15.4% among women) when the same age group were asked if they had tested for HIV at least once in the past 12 months and knew the result. Awareness of testing services varied, with 51% of individuals aged 15–64 being able to identify locations where HIV testing was available. A similar percentage of men who have sex with men (50%) had this knowledge, while 57% of female sex workers were aware.35

Mobile HIV testing in Brazil

The Department of STD/AIDS and Viral Hepatitis has partnered with the NGO EPAH to implement the project “Quero Fazer” (I want to be tested). It targets men who have sex with men and transgender people with the use of a mobile unit. This strategy has been successfully expanded to cities across the country including Recife, Rio de Janeiro, Brasília and São Paulo.

These units reach populations in community settings with high HIV prevalence and those who also face great challenges for early diagnosis, mainly due to issues of stigma and discrimination that are still prevalent in some traditional healthcare facilities.36 As of January 2015, 440 HIV tests had been performed at the mobile unit, with 15 positive results, 10 of which occurred among key populations.37

Antiretroviral treatment (ART) in Brazil

Antiretroviral treatment (ART) coverage (among adults aged 15 years and older) for Brazil was an estimated 55% in 2015.38 This is an increase from 41% in 2013.39 Among those diagnosed (820,000), around 452,000 people have started ART. This equates to 58% of women and 54% of men living with HIV on ART.40

In 2015, around 5,600 children (aged 0-14 years) out of the 7,500 living with HIV were receiving ART, which equates to 76%.41

Free antiretrovirals (ARVs) are available to all Brazilians living with HIV. Brazil began manufacturing generic ARVs in the 1990s and now produces 11 of the 20 ARVs used for HIV and AIDS treatment.42

HIV treatment and care in Brazil is co-ordinated by a decentralised network of specialists, tasked to provide quality care and services to people living with HIV. Known as the Specialised Care Services (SAE), there are more than 700 of these teams located across all Brazilian states. Although quality and consistent care and follow-up is provided, challenges as a result of the demand from new and existing patients has overburdened services.43

Additionally, various measures and actions have been implemented with a focus on HIV prevention and treatment for children and adolescents:

In 2014, the Ministry of Health launched #PartiuTeste, a behaviour change communication campaign developed in partnership with young people that utilises traditional media and social media, especially web-based applications such as Tinder and Hornet. The campaign focuses on the importance of using condoms, HIV testing and starting treatment early. As part of this work, young leaders, especially from key populations, have been identified and mentored.44

In 2012, Brazil adopted the recommended Option B+, in which pregnant women should start treatment regardless of CD4 count, and should not discontinue treatment after childbirth. By 2015, 95% of pregnant women living with HIV were receiving ART. In 2015, less than 500 children (aged 0-14) were newly infected with HIV, a decline on previous years.45

Treatment as Prevention (TasP)

Brazil has been implementing Treatment as Prevention (TasP) since December 2013, which allows for treatment to be initiated immediately after confirmation of an HIV diagnosis, regardless of the CD4 count, which indicates the level of HIV in someone’s body. The implementation of this new approach is intended to improve the quality of life for people living with HIV and reduce the likelihood of transmission.46 As a result of this, in 2015 90% of those on ART in Brazil in 2015 had been virally suppressed. This is significant because, when HIV levels in someone’s body are low (or virally suppressed) they are less likely to pass HIV on.47

HIV prevention in Brazil

The national HIV and AIDS Response for Brazil is situated within the Ministry of Health and is integrated into the Health Strategic Plan. One of the objectives is ‘reducing HIV transmission’.48 The multi-pronged approach involves promoting and improving access to HIV testing and adoption of treatment as prevention, combined with the provision of pre- and post-exposure prophylaxis.

Only 25% of the population reporting condom use in all sexual relations.

Brazil’s Ministry of Health figures state that 96% of Brazilians identify condoms as a barrier that can prevent the spread of sexually-transmitted infections (STIs) and HIV. The knowledge of where to get tested for HIV and access free condoms is considered by the Brazilian Ministry of Health as an indicator of access to prevention programmes.49

However, condom use varies widely, with only 25% of the population reporting condom use in all sexual relations, and 63% reporting use during sex with a casual partner. Reported condom use in key populations is higher than that observed in the general population – 60% of men who have sex with men reported using a condom during their last sexual intercourse in the past 12 months. Among people who inject drugs, reported condom use was approximately 41%. Among female sex workers, condom use at last sexual encounter with a client was more than 90%.50

However, a 2015 review of more than 50 condom use studies in Brazil found, overall, 47% of men who have sex with men reported unprotected anal sex. Among people who use drugs the review found 40% reported never using condoms, which increased to 60% when under influence of psychoactive substances.51

Free condoms and lubricant are widely available, with at least one-third of the general population accessing commodities at public health services, NGOs or other institutions. Among key populations, access is significantly higher – 70% among men who have sex with men and 77% among female sex workers.52

Pre-exposure prophylaxis (PrEP)

As part of its efforts to implement combination prevention, Brazil has conducted a study of pre-exposure prophylaxis (PrEP) among men who have sex with men and transgender women. PrEP refers to ARVs that are given to someone who is at risk of HIV transmission before potential exposure, which has been found to greatly reduce their likelihood of acquiring HIV.53

The pilot study showed a 51% uptake of PrEP among all those who were potentially eligible to receive it, including 67% uptake among potentially eligible transgender women and 78% uptake among those who had self-referred. Rates of uptake were increased when those eligible had a steady partner (58%), assessed themselves as being at high risk of acquiring HIV (61%) and had an HIV test in the previous year (58%).5455 This suggests that the higher an individual’s perceived risk of HIV, the more likely they are to seek and use PrEP.

Brazil is currently preparing to start offering PrEP free of charge to those in need of it via its national Unified Health System.56 However, the range of prevention and care services available to transgender women, people living with HIV and men who have sex with men will all affect how successful Brazil is in implementing PrEP for these groups.57

Barriers to HIV prevention in Brazil

A major asset of Brazil’s HIV response has been its inclusion of a human rights perspective, which focuses on promoting the visibility of health as a right and addressing stigma and discrimination. Despite this, issues of violence and stigma and discrimination, particularly against key populations, remains a challenge.Ongoing collaborations between various governmental departments and civil society support the implementation of several legal and socio-cultural initiatives to promote and protect the rights of all citizens, and also fight homophobia, violence against women and lack of respect for the other.58

The future of HIV and AIDS in Brazil

The Brazilian HIV and AIDS response has received international acclaim for a comprehensive public health approach, which has yielded dramatic results in its more than 25 years of implementation.59 However, HIV and AIDS remains a significant challenge for the country. This is evident particularly in the number of new infections and the scale of the epidemic among key affected populations.

Within recent years there has been a resurgence of the Brazilian national HIV response. It has demonstrated the efficacy of implementing a combination approach to HIV, which has improved early diagnosis and linkages to treatment and care.

Access to ART has been expanded, bringing the total number of people on treatment to 452,000.60 The Brazilian government continues to be a leader in the manufacture of generic ARVs, which has been a key factor in the cost-effectiveness and efficiency of its drug provision.61

Additionally, Brazil has incorporated the funding requirements of its HIV response into its total federal budget, thereby promoting financial sustainability.62 However, in 2015 only 6% of its HIV response budget was allocated to effective prevention. This amount is insufficient to make the significant gains in HIV prevention Brazil hopes to achieve. 63